Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

HMC NM Tetrofosmin

Facility

$502.00

Service Code	HCPCS A9502
Hospital Charge Code	3720475
Hospital Revenue Code	343
Min. Negotiated Rate	$451.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$451.80
Rate for Payer: UnitedHealthcare Commercial	$476.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC NM Tetrofosmin

Facility

$502.00

Service Code	HCPCS A9502
Hospital Charge Code	3720475
Hospital Revenue Code	343
Min. Negotiated Rate	$200.80
Max. Negotiated Rate	$476.90
Rate for Payer: Aetna Commercial	$451.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$215.13
Rate for Payer: Humana Medicare Advantage	$210.84
Rate for Payer: UnitedHealthcare Commercial	$476.90
Rate for Payer: UnitedHealthcare Medicaid	$200.80
Rate for Payer: WPPA Medicare Advantage	$301.20

HMC Oxygen Extension Tubing 14'

Facility

$3.00

Hospital Charge Code	3255028
Hospital Revenue Code	270
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.85
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: Humana Medicare Advantage	$1.26
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: UnitedHealthcare Medicaid	$1.20
Rate for Payer: WPPA Medicare Advantage	$1.80

HMC Oxygen Extension Tubing 14'

Facility

$3.00

Hospital Charge Code	3255028
Hospital Revenue Code	270
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC Suction Canister 1200CC

Facility

$11.00

Hospital Charge Code	3259014
Hospital Revenue Code	270
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.90
Rate for Payer: UnitedHealthcare Commercial	$10.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC Suction Canister 1200CC

Facility

$11.00

Hospital Charge Code	3259014
Hospital Revenue Code	270
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$10.45
Rate for Payer: Aetna Commercial	$9.90
Rate for Payer: Humana Medicare Advantage	$4.62
Rate for Payer: UnitedHealthcare Commercial	$10.45
Rate for Payer: UnitedHealthcare Medicaid	$4.40
Rate for Payer: WPPA Medicare Advantage	$6.60

HMC Suction Tubing 12ft

Facility

$4.00

Hospital Charge Code	3257560
Hospital Revenue Code	270
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.80
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: Humana Medicare Advantage	$1.68
Rate for Payer: UnitedHealthcare Commercial	$3.80
Rate for Payer: UnitedHealthcare Medicaid	$1.60
Rate for Payer: WPPA Medicare Advantage	$2.40

HMC Suction Tubing 12ft

Facility

$4.00

Hospital Charge Code	3257560
Hospital Revenue Code	270
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: UnitedHealthcare Commercial	$3.80
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC Suction Tubing 6ft

Facility

$3.00

Hospital Charge Code	3251076
Hospital Revenue Code	270
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMC Suction Tubing 6ft

Facility

$3.00

Hospital Charge Code	3251076
Hospital Revenue Code	270
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.85
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: Humana Medicare Advantage	$1.26
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: UnitedHealthcare Medicaid	$1.20
Rate for Payer: WPPA Medicare Advantage	$1.80

HMC Suction Yankauer Tip

Facility

$3.00

Hospital Charge Code	3252413
Hospital Revenue Code	270
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.85
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: Humana Medicare Advantage	$1.26
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: UnitedHealthcare Medicaid	$1.20
Rate for Payer: WPPA Medicare Advantage	$1.80

HMC Suction Yankauer Tip

Facility

$3.00

Hospital Charge Code	3252413
Hospital Revenue Code	270
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: UnitedHealthcare Commercial	$2.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HME Heat Moisture Exchanger for trach tubes

Facility

$6.00

Hospital Charge Code	3251632
Hospital Revenue Code	270
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$5.70
Rate for Payer: Aetna Commercial	$5.40
Rate for Payer: Humana Medicare Advantage	$2.52
Rate for Payer: UnitedHealthcare Commercial	$5.70
Rate for Payer: UnitedHealthcare Medicaid	$2.40
Rate for Payer: WPPA Medicare Advantage	$3.60

HME Heat Moisture Exchanger for trach tubes

Facility

$6.00

Hospital Charge Code	3251632
Hospital Revenue Code	270
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.40
Rate for Payer: UnitedHealthcare Commercial	$5.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HME Provox XtraMoist Heat and Moisture Exchanger w/Speak Button Model 7290

Facility

$21.00

Hospital Charge Code	3251634
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$19.95
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: Humana Medicare Advantage	$8.82
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$8.40
Rate for Payer: WPPA Medicare Advantage	$12.60

HME Provox XtraMoist Heat and Moisture Exchanger w/Speak Button Model 7290

Facility

$21.00

Hospital Charge Code	3251634
Hospital Revenue Code	270
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$18.90
Rate for Payer: UnitedHealthcare Commercial	$19.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HME with O2 Adapter Heat and Moisture Exchanger

Facility

$6.00

Hospital Charge Code	3251633
Hospital Revenue Code	270
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$5.70
Rate for Payer: Aetna Commercial	$5.40
Rate for Payer: Humana Medicare Advantage	$2.52
Rate for Payer: UnitedHealthcare Commercial	$5.70
Rate for Payer: UnitedHealthcare Medicaid	$2.40
Rate for Payer: WPPA Medicare Advantage	$3.60

HME with O2 Adapter Heat and Moisture Exchanger

Facility

$6.00

Hospital Charge Code	3251633
Hospital Revenue Code	270
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.40
Rate for Payer: UnitedHealthcare Commercial	$5.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMGCR Ab (IgG) QST

Facility

$400.00

Service Code	HCPCS 83520
Hospital Charge Code	3558352
Hospital Revenue Code	300
Min. Negotiated Rate	$360.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$360.00
Rate for Payer: UnitedHealthcare Commercial	$380.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

HMGCR Ab (IgG) QST

Facility

$400.00

Service Code	HCPCS 83520
Hospital Charge Code	3558352
Hospital Revenue Code	300
Min. Negotiated Rate	$36.48
Max. Negotiated Rate	$380.00
Rate for Payer: Aetna Commercial	$360.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$36.48
Rate for Payer: Humana Medicare Advantage	$168.00
Rate for Payer: UnitedHealthcare Commercial	$380.00
Rate for Payer: UnitedHealthcare Medicaid	$160.00
Rate for Payer: WPPA Medicare Advantage	$240.00

Homocysteine QST

Facility

$291.00

Service Code	HCPCS 83090
Hospital Charge Code	3552110
Hospital Revenue Code	300
Min. Negotiated Rate	$261.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$261.90
Rate for Payer: UnitedHealthcare Commercial	$276.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Homocysteine QST

Facility

$291.00

Service Code	HCPCS 83090
Hospital Charge Code	3552110
Hospital Revenue Code	300
Min. Negotiated Rate	$17.92
Max. Negotiated Rate	$276.45
Rate for Payer: Aetna Commercial	$261.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$176.58
Rate for Payer: Humana Medicare Advantage	$122.22
Rate for Payer: UnitedHealthcare Commercial	$276.45
Rate for Payer: UnitedHealthcare Medicaid	$17.92
Rate for Payer: WPPA Medicare Advantage	$174.60

HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT

Facility

$204.03

Service Code	CPT G0463
Hospital Revenue Code	360
Min. Negotiated Rate	$45.57
Max. Negotiated Rate	$204.03
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$45.57
Rate for Payer: UnitedHealthcare Medicaid	$52.00
Rate for Payer: WPPA Medicare Advantage	$204.03

H. Pylori Ag, EIA, Stool QST

Facility

$71.00

Service Code	HCPCS 87338
Hospital Charge Code	3552114
Hospital Revenue Code	300
Min. Negotiated Rate	$63.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$63.90
Rate for Payer: UnitedHealthcare Commercial	$67.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

H. Pylori Ag, EIA, Stool QST

Facility

$71.00

Service Code	HCPCS 87338
Hospital Charge Code	3552114
Hospital Revenue Code	300
Min. Negotiated Rate	$14.38
Max. Negotiated Rate	$67.45
Rate for Payer: Aetna Commercial	$63.90
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$31.18
Rate for Payer: Humana Medicare Advantage	$29.82
Rate for Payer: UnitedHealthcare Commercial	$67.45
Rate for Payer: UnitedHealthcare Medicaid	$14.38
Rate for Payer: WPPA Medicare Advantage	$42.60

Know your out-of-pocket cost for care.

All Charges